Healthcare in South Africa

Construction in progress on the new Natalspruit Hospital, a public institution, in Vosloorus outside Johannesburg. The public health sector is delivers services to about 80% of South Africa’s population.(Image: Chris Kirchhoff, MediaClubSouthAfrica.com. For more freephotos, visit the image library)

South Africa's health system consists of a large public sector and a smaller but fast-growing private sector.

Introduction

Healthcare varies from the most basic primary healthcare, offered free by the state, to highly specialised hi-tech health services available in the both the public and private sector. The private sector spends about R66-billion to service about 7-million people, while the rest of the population depends on R59-billion spent through the public health sector.

The public sector is stretched and under-resourced in places, while the mushrooming private sector, run largely on commercial lines, caters to middle- and high-income earners who tend to be members of medical schemes (18% of the population), and to foreigners looking for top-quality surgical procedures at relatively affordable prices. The private sector also attracts most of the country's health professionals.

The Department of Health has an overall responsibility for healthcare in the country, with a specific responsibility for public-sector healthcare. High levels of poverty and unemployment mean healthcare is largely the burden of the state. But there has been a real increase in funding for public hospitals, which consume two-thirds of the health budget.

A Health Charter has been developed which aims to create a platform for engagement between sectors so as to address issues of access, equity and quality of health services as well as issues of broad-based black economic empowerment and employment equity.

Expenditure on health

The bulk of health sector funding comes from the South Africa's National Treasury. The budget of the Department of Health grew by 15.3 % from 21.7 billion in 2010/11 to 25.7 billion in 2011/12. Policy areas that received additional funding included:

Total expenditure on the comprehensive HIV/Aids Conditional Grant will amount to R26.9-billion over the medium term, based on an increase in the number of people on treatment from 1.2-million in 2011 to 2.6-million by 2013/14.

At national level an additional amount of R442-million was allocated for the financial year 2011/12 and R692-million for 2012/13 and R2.28-billion for 2013/14. This will be used to improve quality, to strengthen public healthcare teams, to upgrade and maintain nursing colleges, to improve maternal and child health, and for universal coverage of HIV at 350-threshold.

Additional earmarked funding was allocated at provincial level for preparatory work for the National Health Insurance which amounts to R16,1-billion over a three-year period. This will be mainly for registrar posts, specialist posts at district level, for family health teams and for helping hospitals comply with norms and standards.

In 2010, over R8-billion was added to specific health service interventions, laying the foundations for National Health Insurance. This included:

Funding for the Department of Health to lead the necessary institutional and management reforms, Revitalising health infrastructure, including a new infrastructure grant for provinces

Expanding capacity to train medical doctors and nurses.

Although the state contributes about 40% of all expenditure on health, the public health sector is under pressure to deliver services to about 80% of the population. Despite this, most resources are concentrated in the private health sector, which sees to the health needs of the remaining 20% of the population.

Drug expenditure per person varies widely between the sectors. In 2000 about R8.25-billion was spent on drugs, with the state spending only 24% of this. Thus, R59.36 was spent on drugs per person in the state sector as opposed to R800.29 on drugs per person in the private sector.

In 2003, the government launched the Hospital Revitalisation Programme, with a total budget of R1.9-billion, in an attempt to improve the public health system. Under the programme, hospital infrastructure, procurement of the necessary equipment and management skills are being improved. Local hospital management has the delegated authority over operational issues such as the budget and human resources in order to facilitate quicker response to local needs.

Public health consumes around 11% of the government's total budget, which is allocated and spent by the nine provinces. How these resources are allocated, and the standard of healthcare delivered, varies from province to province. With less resources and more poor people, cash-strapped provinces such as the Eastern Cape face greater health challenges than wealthier provinces such as Gauteng and the Western Cape.

The Department of Health has attempted to reduce the cost of medicines by introducing a single exit price system as well as setting a dispensing fee for pharmacists. The latter issue has resulted in a legal challenge by some members of the pharmacy profession.

Transforming the health sector

After South Africa's first democratic elections in 1994, the dismantling of the country's race-based health system began. Previously, hospitals were assigned to particular racial groups and most were concentrated in white areas. With 14 different health departments, the system was characterised by fragmentation and duplication.

Lack of data has to some extent impeded the process of transforming the health system. In 2006, new developments include the increased accessibility of disaggregated data at district level and greater coverage of the Millennium Development Goals indicators. However, quality of data, accessibility and inadequate levels of disaggregation are challenges that still need to be addressed.

Over the past few years the health sector has undergone rapid change to make it more equitable and accessible to the needy. Since 1994, more than 1300 clinics have been built or upgraded. Free healthcare for children under six, and for pregnant or breastfeeding mothers, has been introduced.

A number of tertiary hospitals and other hospitals have been completed in recent years. In 2007 alone 29 hi-tech hospitals were under construction all around South Africa.

The renewal of hospital stock focused initially on renovation and maintenance, but has progressed to major rebuilding under the Hospital Revitalisation Programme. In terms of the health department's overall investment in this scheme, by the end of the 2007/2008 financial year the total investment was about R5.4-billion. In the 2008/2009 financial year the programme received an allotment of R2.8-billion, R3.1-billion in 2009/2010, and R3.6-billion in 2010/2011.

By June 2006 there were 400 provincial public hospitals. A service package with norms and standards has been developed for district hospitals and is being extended to regional hospitals.

The number of private hospitals and clinics continues to grow and there are 200 private hospitals. The mining industry also provides its own hospitals, and has 60 hospitals and clinics around the country.

The policy on universal access to primary healthcare, introduced in 1994, forms the basis of healthcare delivery programmes. The number of people using these facilities increased significantly across provinces between 2003/04 and 2004/05. In the Eastern Cape, primary healthcare head counts increased from 13.9-million in 2003/04 to 17.7-million in 2004/05. During the same period in KwaZulu-Natal, the figure increased from 18.5-million to 18.8-million, and in Mpumalanga from 6-million to 6.5-million. Primary healthcare provided to under-five-year-olds also increased in the Eastern Cape, Mpumalanga and Western Cape.

A new administrative structure is being put in place which will see primary healthcare clinics fall under the auspices of district authorities while hospitals remain under the control of provincial authorities.

A district-based health system is being developed to ensure local-level control of public health services, and to standardise and co-ordinate basic health services around the country to ensure that healthcare is affordable and accessible. A total of 53 health districts have been established in line with the new metropolitan and district municipal boundaries.

Since April 2006, forensic mortuaries have been vested under the authority of provincial departments of health. A modernisation plan to improve the quality of the forensic service has been developed. More than R1.5-billion was been allocated for the implementation of the plan up until 2010.

Doctor shortages

In 2007 the government entered into an agreement to recruit 2 000 Tunisian doctors to combat the long-standing shortage of doctors in rural areas. In addition, 450 doctors from Cuba and Iran have also been employed by the Department of Health. Johannesburg Hospital has entered into an agreement with Maputo Central Hospital which will lead to patient referral and exchange of health professionals between the two hospitals.

The government has also made it easier for other foreign doctors to register here. Newly graduating South African doctors and pharmacists now complete a year of compulsory community service in understaffed hospitals and clinics.

In 2004 the government launched the Community Health Worker Programme to develop community-based generalist health workers. Their training combines competencies in health promotion, disease prevention, primary healthcare and health-resource networking, as well as coordination. It is estimated that there are 40 000 such workers in the country.

In April 2006, the Department of Health launched the National Human Resource Plan in an attempt to make up for the skills shortfall and to compensate for the loss of experienced health professionals from rural to urban areas, from the public to private sector, and from South Africa mainly to developed countries.

To lighten the workload at health facilities, a new cadre of health professionals called clinical associates was introduced in January 2007. Graduates will work under the supervision of medical officers in district hospitals and primary healthcare level.

By November 2010, 150 509 qualified health practitioners in both public and private sectors were registered with the Health Professions Council of South Africa, the health practitioner watchdog body. This includes 30 006 doctors and 5 185 dentists. Doctors must comply with the Continuing Professional Development System, which compels them to attend regular workshops, seminars and refresher courses to retain their yearly registration.

Regulations in the private health sector are effected through the Council for Medical Schemes. The Medicines Control Council is charged with ensuring the safety, quality and effectiveness of medicines.

The National School Health Policy and Guidelines, which aim to ensure that all children have equal access to school health services

The Medicines Control Council is making efforts to regulate complementary medicines by calling on producers to submit products to assess their contents, and to establish a regulatory framework for them

In 2006, the implementation of the National Health Act of 2003 was initiated. Some provinces are engaged in aligning their provincial legislation with the national Act.

Children's health

The major preventive interventions include immunisation, the Integrated Management of Childhood Illness (IMCI) strategy, childhood infection prevention, neo-natal health and developmental screening. There have been some improvements in the delivery of interventions, including the meeting the 90% under-one immunisation coverage goal, the extension of IMCI services to all districts in the country and the continued decline in notifiable diseases in children.

The lack of food security has led to widespread malnutrition among young South Africans, and has placed increased demands on the health system. Child nutrition is being addressed through the Integrated Nutrition Programme (INP).

Targets have been met in the Baby-Friendly Hospital Initiative; legislation relating to the mandatory fortification of maize meal and wheat flour with multiple micronutrients; mandatory iodization of salt; and the provision of Road-to-Health Charts.

Children require the prior consent of a legally competent third party in order to obtain healthcare, and this could be undermining access to treatment for HIV/Aids.

Women's health

South Africa is a signatory to several international commitments such as the Millennium Development Goals (MDGs), and the latter seek to address the health needs of women and children. However in SA the health of mothers and children remains poor. The latest national statistics reflect a steady increase in infant and under-five mortality and less than optimal maternal health status. Up to the end of 2010 the infant mortality rate was around 43.2 per 1 000 live births. Cervical cancer remains the most common cancer among South African women.

Public-private partnerships

To address some of the resource and personnel shortages facing the public sector, partnerships between the public and private sectors are slowly being forged. Some private hospitals are now offering beds and providing medical care to public sector patients. They are also beginning to offer post-graduate teaching facilities to university medical faculties in an effort to stop the flow of doctors out of the country.

In May 2006, the Minister of Health, Dr Manto Tshabalala-Msimang, launched the National Consultative Health Forum. The forum will bring together more than 250 people representing health professionals, researchers, health activists, the private health sector and organised labour for discussions on key strategic health issues, including tuberculosis, HIV/Aids, recruitment and retention of health professionals, and transformation of the health sector.

Poverty, Aids and TB

Aids and other poverty-related diseases like tuberculosis and cholera are placing a tremendous strain on South Africa's healthcare system. HIV/Aids poses the biggest threat by far, with an estimated 6-million South Africans expected to die from Aids-related diseases over the next 10 years. The province of KwaZulu-Natal has the second-highest rate of Aids infection in the world, after India.

In 2008, the national prevalence of HIV in citizens over the age of two years was reported to be around 10.9%, and in 2009 29.4% of mothers attending antenatal clinics were HIV positive. These figures are based on a collaboration between the Department of Health, UNAids, World Health Organisation and other groups in South Africa which undertook the spectrum mathematical model to estimate the HIV prevalence in the general population.

Since 2006 HIV was found to be the leading cause of death among adult men and women in the country. HIV- related diseases and non HIV- related TB and pneumonia are the leading causes of death among women.

According to Statistics South Africa, in 2007 the number of people who died from Aids was 603 094. However, in 2008 this figure was 592 073 - a decline of 1.8%.

SA has the fifth-highest number of notified TB cases in the world. In 2009, the prevalence of burden stood at 818 people per 100 000 of the population. At least 12% of TB patients defaulting on their treatment.

The TB cure rate for smear-positive cases remains low at 50.1%, with a successful treatment completion rate of 62.9%. The Medicines Research Council (MRC) has put multidrug-resistant TB at 6.7% in previously treated patients.

The implementation of the Directly Observed Treatment Strategy (DOTS) - where health workers monitor and observe TB patients taking their medication - in most clinics around the country has made significant inroads into controlling the disease.

Many of those with HIV/Aids depend on home-based care. Postnatal transmission of HIV from mother-to-child through breast milk remains a key challenge despite the availability of replacement feeds as part of the national Perinatal and Maternal Morbidity and Mortality Rate Programme.

While there have been significant improvements in maternal care (antenatal care attendance and deliveries conducted by skilled health worker recorded high percentages of 90% and 92% respectively, in 2006) maternal deaths are on the increase, mostly due to the HIV/Aids epidemic.

For many South African HIV-infected women, decision making in regard to pregnancy and childbirth is hampered by number of factors including lack of information on contraception, interactions between antiretroviral therapy, drugs for treatment of opportunistic infections and lack of knowledge about their HIV status when they become pregnant.

Many nongovernmental organisations, have risen to this challenge, mounting tremendous efforts to create awareness around HIV/Aids, promote behaviour change, and provide assistance to those affected by the epidemic. The Department of Health allocated a budget of R56-million for the support of NGOs involved in the response to Aids and TB in 2006/07.

Expenditure on dedicated programmes for HIV/Aids within provincial health budgets has grown and the HIV/Aids grant now stands at R1.9-billion.

In April 2006, the Accelerated Prevention of HIV/Aids Initiative was launched as part of an extensive initiative regarding prevention by the member states of the Africa region of the WHO. More than 1 060 health professionals have been recruited to support the programme. Some 7 600 health professionals have been trained in the management, care and treatment of HIV/Aids.

South Africa has an extensive antiretroviral treatment programme, with 213 000 patients initiated on antiretroviral treatment by the end of September 2006, and an estimated additional 90 000 to 100 000 patients initiated in the private and nongovernmental sector.

The government also provides free condoms for the prevention of sexually transmitted diseases.

Malaria

In 2009 the World Health Organisation reported that only 4% of the population is at high risk of malaria and 6% at low risk, while 90% live in malaria-free areas. Almost all cases are caused by Plasmodium falciparum.

Confirmed malaria cases decreased from an annual average of 36 360 during 2000–2005 to 6 072 cases in 2009 (83% reduction). Reported malaria deaths fell from 127 to 45 (65% decline) in the same period. The programme implemented IRS as its principal vector control intervention, protecting about 4-million people per year (78% coverage).

About 10% of the population lives in malaria-risk areas. The prevalence of malaria in South Africa has increased steadily from the mid-1980s, with a rapid increase since 1996. South Africa is a signatory to the Abuja Declaration, which undertook to reduce malaria morbidity and mortality by 50% by 2010.

However, malaria occurs only on the fringes of the country, affecting the three north-eastern provinces: KwaZulu-Natal, Mpumalanga and Limpopo. Malaria transmission occurs seasonally, with peak rates of infection occurring in April and declining by June.

Distribution of bed nets has seen the number of malaria cases in the northern parts of KwaZulu-Natal reduced by 70%.

Cholera

The lack of access to clean water by poor people in many parts of the country has resulted in a few outbreaks of cholera, with the epidemic of 2000-2001 being the worst and affecting approximately 120 000 people. Despite the large number of people who became ill, the case fatality rate was relatively low with only 265 deaths reported. Epidemics usually occur in under-serviced areas - where neither clean water, nor health services are available.

Two new rotaviral vaccines (RotateqTM and RotarixTM), have been released. While these vaccines will soon be available to children in the private health sector, its prohibitive price means that they will not be available to the public health sector.

Vaccination and immunisation

The WHO honoured SA for its critical contribution to global public health with the award of a recognition certificate to the Department of Health in May 2007, to mark a 10-year successful implementation of the vaccine vial monitors (VVM) to improve access to immunisation. Its use over the last 10 years has made it possible for more children in more places to have access to the vaccine.

In May 2007, the Department of Health launched a nationwide Polio and Measles Immunisation Campaign that is aimed at boosting the immunisation coverage to reach the required target of 90%. The last wild polio virus case to be detected in SA was in 1989, but there have been others elsewhere on the continent and there is the risk of it being imported.

In 2006, the Medicines Research Council (MRC) initiated toxicology studies to further study selected indigenous plants. To protect the intellectual property rights of traditional peoples, the MRC will conduct biomedical research on medicinal plants.

South African President Thabo Mbeki appointed a presidential task team to look into all aspects of the promotion and regulation of African traditional medicines, including the development of a pharmacopeia.

<p>In terms of our overall investment in the Hospital Revitalisation Programme I am happy to announce that since its inception, we have so far invested about R5,4 billion as at the end of 2007/08 financial year. In this financial year, 2008/09, we have allocated to this programme R2.8 billion, R3, 1 billion in 2009/10 and R3, 6 billion in 2010/11. In the current financial year 48 projects are receiving funding, of which 37 hospitals are in construction and 11 are in different planning stages. </p>